P R O G R E S O S D E

Obstetricia y

Revista Oficial de la Sociedad Española

de Ginecología y Obstetricia
Ginecología
Revista Oficial de la Sociedad Española de Ginecología y Obstetricia
Prog Obstet Ginecol 2019;62(2):107-111
Perspectiva

Towards a comprehensive perspective in the care of complicated

pregnancies: 10 key points from a psychosocial perspective
Hacia una perspectiva integral en la atención a las gestaciones de riesgo. Aportación de un
decálogo desde una perspectiva psicosocial
Ernesto González-Mesa, Marta Blasco-Alonso
Sección Ginecología y Obstetricia Psicosomática. Departamento de Especialidades Quirúrgicas, Bioquímica e Inmunología de la Universidad de Málaga.
Hospital Regional Universitario de Málaga

Abstract
For a pregnant woman, the diagnosis of a high-risk pregnancy threatens the course of the pregnancy and even
the woman’s own life. Management of these cases requires not only that professionals have appropriate technical
Key words: skills, but also that the woman is provided with the necessary tools to help her face a "complicated pregnancy"
High-risk-pregnancy. and accept the possible consequences. Therefore, it is necessary to address these problems under a compre-
Emotions. hensive perspective that ranges from the sociocultural features to the woman’s own attitude towards pregnancy.
Prematurity. We present 10 key points that should be taken into account by obstetricians caring for women with complicated
Antenatal diagnosis. pregnancies.

Resumen
El diagnóstico de riesgo durante el embarazo representa para la gestante una amenaza para el desarrollo del
Palabras clave: embarazo o incluso para su propia existencia. El manejo de estos casos precisa una adecuada formación técnica
de los profesionales, pero también es necesario ofrecer a la gestante herramientas que le ayuden a afrontar
Gestación de
la situación de “embarazo complicado” y a aceptar las posibles consecuencias. Resulta necesario abordar los
alto riesgo.
Emociones. problemas obstétricos bajo una perspectiva integral que incluya desde las dimensiones relacionadas con las
Prematuridad. condiciones socioculturales del entorno hasta su propia actitud ante la gestación. Presentamos en forma de
Diagnóstico decálogo los aspectos a incorporar por los equipos obstétricos encargados de la atención a las pacientes con
prenatal. gestaciones complejas.

Correspondencia:
Ernesto González-Mesa
Departamento de Especialidades Quirúrgicas,
Recibido: 09/09/2018 Bioquímica e Inmunología de la Universidad de
Aceptado: 15/01/2019 Málaga
Facultad de Medicina. Universidad de Málaga
González-Mesa E, Blasco-Alonso M. Towards a comprehensive perspective in the care of Boulevard Louis Pasteur 32
complicated pregnancies: 10 key points from a psychosocial perspective. Prog Obstet Ginecol 29071-Málaga
2019;62(2):107-111. DOI: 10.20960/j.pog.00176. e-mail: egonzalezmesa@uma.es
108
From the moment a woman becomes pregnant, mul-
tiple factors affect her emotional status (Fig. 1). In par-
ticular, the consequences of a diagnosis of a high-risk
pregnancy are very often a source of psychological ten-
sion in that they represent a real threat for the course of
the pregnancy or even for the woman’s life. Occasionally,
fear of the physical pain the condition involves and the
disability arising from treatment and management proto-
cols are a major source of internal conflict, with the result
that the interests of the patient and those of her child are
contradictory.
Relationships
Health
Knowledge
status
Emotional
stability
Personal
Pregnancy
history
Figure 1. Factors affecting the patient’s emotions.
The sensation of loss of control of one’s own body felt
to a greater or lesser extent by all pregnant women is
increased in patients with complications, especially when
these are unexpected. In women with complicated preg-
nancies, there are 3 sources of emotional tension: the
fetus, the mother herself, and the mother’s environment.
Consequently, her problems must be addressed based on
an integrated approach that covers dimensions associated
with her immediate sociocultural conditions and goes so
far as to include her own attitude to her pregnancy.
Categorizing a pregnancy as "high-risk" stigmatizes the
patient, compromises her self-esteem, and often modifies
her expectations of a successful pregnancy in a catastro-
phizing, unrealistic way. Management of these cases by
the obstetrician requires an appropriate diagnosis and
medical treatment, although it is equally necessary to
provide the patient with the necessary tools to help her
address a "complicated pregnancy" and to accept the pos-
sible consequences.
E. González-Mesa et al.
Very often, the patient will have to accept leaving her
job, admission to hospital, and the need for treatment. In
addition, she must prepare for the care of her child, who
may by ill or have special needs. Therefore, her pregnancy
will differ considerably from what she had imagined.
Addressing her problem by taking into account the
positive aspects of professional care rather than focus-
ing on the problem or probability of failure will make
the patient less vulnerable. In our experience, pregnant
women feel better when we consider them as requiring
"special care" than when we describe them as having a
high-risk pregnancy.
ANTENATAL DIAGNOSIS
Fortunately, most of the antenatal diagnostic proce-
dures in population-based screening programs in our set-
ting yield normal results. Therefore, emotional conflict is
limited on most occasions. However, the often predictive
and probabilistic nature of tests means that we are obliged
to rule out or confirm findings based on tests with great-
er diagnostic power. It is necessary to manage both the
resulting uncertainty and fetal and infant prognoses using
terms indicating whether or not something will happen
or not within a specific time period. A diagnosis of fetal
abnormalities or malformations requires us to decide on
how to address the problem.
When the abnormality is clear and of a specific degree
of severity, the patient, guided by the obstetrician, will
restructure her thought processes, channel her feelings,
and even think about the health of the child she is about
to have. The type of abnormality and time of diagnosis
are key factors in helping the patient to organize her
thoughts, since some diagnoses carry considerable social
stigma, whereas others directly affect the quality of life
of the child.
In our opinion, excellent technical training should be
combined with the best diagnostic approaches available
and sufficient time for examinations. However, a key factor
is the need for the maternal-fetal medicine specialist to be
appropriately trained in assertive communication and in
the resolution of ethical conflicts. In this sense, we would
like to point out 3 main ideas.
First, we stress the impact of information. During the
antenatal diagnosis, especially in the case of popula-
tion-based screening, it is important for the patient and
her partner to know the significance of the test and its
results, as well as potential alternatives and their limits.
Assertiveness and empathy at the initial contact are key
elements that will ensure that the patient is receptive to
information on possible findings. Therefore, providing her
with a document requesting signed consent will be of no
use if it is not accompanied by appropriate clarifications
after reasoned and targeted reading.
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TOWARDS A COMPREHENSIVE PERSPECTIVE IN THE CARE OF COMPLICATED PREGNANCIES: 10 KEY POINTS FROM A
PSYCHOSOCIAL PERSPECTIVE
Second, correct performance of the test requires the
commitment of the whole team so that the patient and
her child have access to appropriate technical facilities,
the time necessary for examinations, and the ideal phys-
ical space in order to ensure respect for the patient’s
privacy, both when she undergoes the test and when
she expresses her emotions after the diagnosis, which is
sometimes made in the antenatal diagnosis unit.
Finally, it is worth pointing out that in any medical dis-
cipline, the physician’s own prejudices and stereotypes
will necessarily lead to erroneous categorization. Not all
pregnant women follow the same thought paths, since
not all experience the same emotions or have the same
degree of knowledge about their situation, with the result
that it is necessary to provide information on an individ-
ual basis, even to the extent that we take particular care
with the vocabulary we use. Moreover, the patient does
not necessarily think in the same way as the professional
who is providing her with information; therefore, it is inap-
propriate for the health professional to impose his/her
criteria in the management of difficult cases, irrespective
of how objective these criteria may seem.
In our opinion, providing objective information does not
require the professional to be cold or inflexible. In this
sense, it is worth pointing out that there is never only a
single alternative when a severe condition is diagnosed,
and even less so when the alternative proposed is a ter-
mination. Many patients request antenatal palliative care,
which is based on company, support, information, and
empathy from the attending professionals up to the time
of the birth.
THE RISK OF PRETERM BIRTH
On most occasions when a medical, surgical, or obstetric
problem complicates pregnancy, a key danger to be man-
aged is that of the risk of preterm birth. The spectrum of
potential adverse physiological and functional outcomes
that can lead to neonatal death and severe morbidity
means that symptoms and problems pointing to prema-
ture labor can generate considerable stress and anxiety
in the patient.
A large number of pregnant women visit the emergency
department with preterm contractions for which medical
treatment could prevent labor and make it possible to
extend the pregnancy by days or weeks. In these patients,
admission to hospital—where necessary—is usually short;
therefore, training them to recognize specific symptoms
would enable them to return to their family environment
and be followed up with regular outpatient visits. They
would therefore feel that they maintain some degree of
control over their situation. Of course, the threat of a
preterm birth is a turning point in the natural history of a
pregnancy and one at which the woman’s experience of
[Prog Obstet Ginecol 2019;62(2):107-111]
109
the remainder of her pregnancy will depend largely on the
guidance from her obstetric team. She should be provided
with resources that enable her to face her new status as a
"pregnant woman with special needs" and to prepare for
a potentially poor perinatal outcome, understood in this
case as the birth of a preterm baby.
The situation is different when the risk of preterm birth
arises from early rupture of membranes, cervical insuffi-
ciency, or other irreversible conditions. These situations
generally involve long-term admission to hospital, proba-
bly until the end of pregnancy, thus removing the woman’s
control over her life. She is required to stop working, leave
her home, and must often move to hospitals in other parts
of the country. In addition, she may have other children
who have to be cared for by relatives, friends, neighbors,
or even public institutions. These patients clearly con-
stitute a particularly vulnerable group in psychological
terms, with the result that emotional support is essential
throughout the process (1).
Aside from a situation that involves the patient being
excluded from her normal life as a result of the compli-
cations, clinical management requires a complex balance
between 2 therapeutic strategies that sometimes pull in
opposite directions (1,2): on the one hand, optimization
of outcomes in terms of fetal health (avoiding, where
possible, fetal infection and minimizing the effects of
preterm birth and its sequelae); and, on the other, opti-
mizing outcomes in terms of maternal health (reducing
the risk of sepsis and preventing complications associat-
ed with treatment).
Ambivalent feelings are therefore very common: the
patient wishes the pregnancy to end as soon as possible
and to avoid the birth of a preterm infant with potential
sequelae (brain hemorrhage, respiratory distress, and
other problems). It is logical that the woman wants the
pregnancy to finish as soon as possible, since, as we have
seen, diagnosis involves a considerable degree of physical
suffering owing to the need to remain in hospital, with
continuous treatment and diagnostic tests. However, the
pregnancy may have to be brought to a close at any time,
and many cases are considered emergencies in which a
preterm birth is unavoidable (1-3).
The patient and the medical team should manage any
uncertainty about the duration of pregnancy (extremely
premature vs late), the approach to concluding the preg-
nancy (elective vs emergency, cesarean vs vaginal), peri-
natal outcome (severe neonatal morbidity vs moderate
neonatal morbidity), and long-term outcome (normal vs
special needs). This, together with a setting in which the
patient has no control over her own body, places her in
one of the most stressful situations she can experience.
The perinatal team should be aware of this and provide
tools to manage the situation.
Years of experience caring for women hospitalized
because of complicated pregnancies has shown us the
110
need for the obstetric team to bear in mind the following
10 points:
1. The patient is the focus of the process
The patient should be at the very center of the process.
Both her and her child’s health must be the objectives on
which any action taken is based. Every attempt should
be made to avoid the problems generated as a result of
the multiple pressures of the health system or because of
the patient’s own personality or that of the team caring
for her.
2. Gestational age is a continuum
Every day in utero is important for the development of
the child. Fetal maturation is a gradual process, and as ges-
tational age increases, the number of potential problems
for the child decreases. We should not set medium- or
long-term timeframes for patients who are admitted for
long periods. The objective is not to reach a given week
of gestational age, but to be happy that another day has
passed without incident.
3. Training in coping strategies
Cognitive-behavioral orientation therapy includes
interventions aimed at enhancing skills that can help the
patient cope with the situation in which she finds herself.
Training in relaxation, breathing techniques, self-instruc-
tion, and cognitive control are appropriate strategies for
women with complicated pregnancies.
4. Reinforcing messages
Communication between professionals and the patient
is essential at every point during pregnancy. However, it is
also important to transmit messages that stress the effort
required to follow our indications. Thus, we give meaning
to the change occurring in the patient’s life and transmit
our admiration for the way in which she strives to prolong
the pregnancy.
5. Anchor messages
Anchor messages remind the patient of our interest and
that of the whole obstetric team attending her so that the
outcome of pregnancy is successful. We thus show how we
aim to achieve the best possible outcome, by doing all that
we can and should, on both a personal and scientific level.
E. González-Mesa et al.
6. Appropriate level of information
We believe that the patient should always know whether
we believe a situation is stable or not, or whether changes
are expected in the short or long term. We should insist
on the idea that the obstetric team is suitably prepared
to act at any time, when necessary.
7. Boost confidence in the team
We should transmit to the patient our experience in the
management of situations such as hers. Where possible, we
should provide data on the prevalence of her complication,
as well as our results, so that she knows what to expect
from the situation in terms of poor or favorable results.
8. Assess her emotions
We must openly show our interest for the patient’s
psychological health and state of mind. We can do so
by preparing direct questions aimed at encouraging her
to express her feelings, emotions, fears, and needs with
respect to her situation. It is important to point out that
both a suitable diet and sufficient reparative sleep play a
key role in regulating her emotions.
9. Know the context of the patient’s relationships
It is necessary to identify the person who accompanies
the patient during admission in order to ensure the cor-
rect approach to her social and family situation and the
support she is counting on. It is often more appropriate to
hold an initial interview with the patient alone. During this
interview and afterwards, we can learn about her environ-
ment in order to identify the person who can best sup-
port her. We can also determine which aspects the patient
wishes to share and which she prefers to restrict to the
private relationship between herself and her physician.
In addition, the patient will sometimes tell us whether
she prefers to be accompanied when we provide her with
information or whether she prefers the person accompa-
nying her to be informed only about specific aspects on a
separate occasion.
10. Accompany the patient when important decisions
are to be taken
We should accompany the patient whenever an import-
ant decision is to be taken. We must ensure that she
knows that we will be with her in any possible scenarios
that arise from her decisions. We should make every effort
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PSYCHOSOCIAL PERSPECTIVE

to accompany her when important decisions are to be tak- REFERENCES

en. Moreover, we must accept her criteria above all else,
even above our own personal ideas, without judgment
or prejudice.
Table I.
Ten key points for the management of pregnant women
at risk of preterm delivery
1. Höglund E, Dykes AK. Living with uncertainty: A Swedish qualitative
interview study of women at home on sick leave due to premature
labour. Midwifery 2013;29(5):468-73.
2. Rubarth LB, Schoening AM, Cosimano A, Sandhurst H. Women’s
experience of hospitalized bed rest during high-risk pregnancy. J
Obstet Gynecol Neonatal Nurs 2012;41(3):398-407.
3. Carter J, Tribe RM, Shennan AH, Sandall J. Threatened preterm
labour: Women’s experiences of risk and care management: A qua-
litative study. Midwifery 2018;64:85-92.

I Make the woman the center of the process

II Avoid strict timeframes

III Practice coping strategies

IV Reinforce the woman’s behavior

V Create anchor messages

VI Provide an appropriate level of information

VII Promote confidence in the team

VIII Evaluate emotions daily

IX Know her social environment

X Accompany her in her decisions

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